Letter

A case of self-disembowelment is presented with an overview of self-disembowelment
as a cultural entity.

A 26-year-old Chinese woman was found by alarmed paramedics outside her house while
attempting to remove her bowels through a self-affected cut in her stomach with a
30 cm kitchen knife. Vital parameters were intact and there were no traumatic findings
apart from a small left paramedian cut of approximately 5 cm in her upper abdomen.
She was confused, and even in the shock room the patient proceeded with her attempts
to remove her bowels.

The most striking finding at computed tomography scan was the total absence of the
small bowel, later confirmed during surgery (Figure 1). The police were contacted to see whether they could trace the missing bowels, and
indeed several pieces of bowel, cut into pieces during the removal procedure, were
found in the surroundings of the patient's house. The missing pieces were brought
to the hospital but unfortunately were not found to be viable and replacement was
considered futile (Figure 2).

Figure 1.Abdominal computed tomography image showing the total absence of the small bowel.

Figure 2.Pieces of bowel, cut into pieces during removal. Several pieces of bowel, cut into pieces during the removal procedure, were found
by the police in the surroundings of the patient's house.

Notorious is the Japanese ritual suicide known as harakiri (spoken term) or seppuku (written term), which literally means 'cutting the belly' - the honorable method of
taking one's own life practiced by men of the samurai (military) class in feudal Japan
[1].

The ancient Egyptians believed that toxins formed as a result of decomposition within
the intestines. This perception still exists, as evidenced by the plethora of advertisements
for colon cleansing. In combination with the tough image of samurai committing seppuku, this leads to phenomena such as the Australian death metal band Disembowelment and
songs such as 'Self Disembowelment' by Devourment, with lyrics such as 'I must release
these vile insects from inside of me' - although the lyrics as a whole are quite difficult
to follow [2].

Rare examples of self-disembowelment include the report of a New Jersey man who allegedly
cut out his entrails in front of police and then threw bits of his intestines at them
[3]. Also, a case is mentioned in the 1968 edition of the Atlas of Legal Medicine [4].

As a result of her self-inflicted injury, our patient developed a short bowel syndrome
for which intestinal transplantation has been advocated. However, survival rates and
quality of life are better in patients on chronic parenteral nutrition [5]. Owing to ongoing mental problems, transplantation would be unfeasible and the expectation
is that she will be dependent on lifelong parenteral feeding.

Competing interests

The authors declare that they have no competing interests.

Acknowledgements

The study complies with the Declaration of Helsinki and good clinical practice guidelines.
The patient gave permission to publish this manuscript.